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Tuesday, December 6, 2016

Go CDF Yourself!




Some years ago I was asked to do a presentation to an international sales and service team in the medical device industry. I attended their global sales meeting, with my presentation planned for the last day… it was to be motivational… “get them to achieve more with their customers” was my direction.

I attended all of the three day meetings to get used to the technology they were selling and servicing… good thing, since it became clear to me that my planned presentation was totally wrong. This group of people had a long way to go before they were a team, and if I could recognize it, the customers could, too.

The internal and external sales, service and marketing functions all had managers who were in silos, reporting to the President/CEO. Each had his own set of goals and incentives… and upon analysis, some were at cross-purposes. While this wasn’t going to change, it became clear to me that it needed to become more seamless. The teams didn’t trust one-another… sales felt marketing wasn’t giving them the right tools; marketing felt sales didn’t know how to sell the product; service thought sales over sold product capabilities, leaving them to clean up the too-high expectations.

The company also had product problems with the customers who, it appeared, felt the product did what several other incumbent products did… and was more expensive. This was leading to frustration throughout the company, and a low  productivity level (sales to FTE ratio) that was not sustainable.

After discussions with the CEO I asked to do a very casual presentation with all three groups  attending the meeting… sales, service and marketing… the teams had direct interfaces with customers, and each other. It was to be a low-tech discussion… flip chart, markers, casual seating (it turned out to be a dinner presentation), after-dinner drinks on the tables!

I worked through the issues that I saw… and new needed to be addressed:

a)     The teams had no credibility with each other, or the customer.

b)     They were focused on telling about their product, instead of positioning it visa vis the status quo, in each account. They were unable to differentiate their product as a result… customers were not buying it.

c)     This enterprise group was the most up-tight I had met; almost disliking each other as teams, and as individuals. They were not having fun, and turn-over had become a problem for the sales and service departments.

Credibility is the currency of success… establishing it as a team, and as individuals internally in companies, is critical to success. This is done through strong internal communications before, during and after products are developed, tested, launched and sold. All commitments should be made realistically, so that success is achievable. Product, market analysis, selling tools, product training and so on, should all be coordinated before launch. I liken this to selling among the internal teams (ensuring marketing knows sales’ needs; sales knowing what service needs to achieve its goals, and so on). Ensuring that those needs are satisfied first, helps with achieving the enterprise’s goals. Transparency throughout the process is critical; to get it right with one another, before trying to get it right for the external customer.

Credibility with the customer is a similar situation. A sales person, internal or external, needs to establish her credibility, before customers will trust the company. Then the company has to come through with a product and service that meets the expectations that were established by the sales person. Credibility soars when things go wrong and the team comes together with service to ensure the product issues are resolved.

Once the teams have internal credibility with one another, they have a better opportunity with the customer.

Differentiation is the second area of opportunity I wanted to address. This is the problem of the customer not recognizing the utility of the new product verses what they already had been successfully using… the status quo. Learning how to differentiate product from competition and status quo is a fundamental of selling. Sales people cannot successfully sell if the marketing and engineering teams don’t give them product, selling tools and training to clearly define the new product.

Differentiation necessitates a deep understanding of the customer’s processes and the competitive products and companies. As marketing and its allied teams develop product specifications, this should be a core strategy… even products with clear advantages may not be differentiated to “the tipping point” * where customers will rationalize the price and conversion cost differences. Training programs for sales people have been in place for years to try and establish this situation… but without product, selling tools, sales support, service and so on, all combining into a strong proof… customers will not recognize it, and not buy it.

As I discussed the concept of differentiation with the full group, I could see heads nodding and questions/statements started. It became clear that if the teams worked together, they could also impact their credibility with each other. Just fifteen minutes into the discussion, I asked the teams to introduce themselves, with a one-line statement about whatever they wanted the others  to know about them. Then I asked them to switch seats at their tables or between tables… clearly there was discomfort… the personalities, history and so on between desperate groups was significant… no less so, just because they are working for the same company.

I then started discussing the apparent silos between each group and how it was causing a clear lack of enjoyment, enthusiasm and fun at the meeting. Employees spend 40 to 80 hours a week with other employees… depending on one another. If it isn’t some level of fun, it is not worth doing. I actually encouraged the teams to find a way to have fun at the meeting and subsequently, in all interactions. When you aren’t having fun, you may as well be somewhere else… shocking the executive of the company, I encouraged those not having fun, to leave… even to leave the company. Shock treatment is old school, but sometimes works…

It wasn’t long before the participants were joking about having fun! It became fun to be with the team. A subsequent presentation that evening from the head of the sales team echoed several of the themes I had initiated, and it became OK to be talking across team lines, that evening.

I ended the presentation by taking the first letters of credibility, differentiation and fun and making the acronym CDF! My final exhortation to the company was “go CDF yourself”. They did, and the company gradually found ways to success… not just with CDF of course… but subsequent corporate successes were grounded in the concepts from that evening.**





*Malcolm Baldrige… The Tipping Point

** Yes, in the following year, I was honored to become a manager in the company, and utilized the “CDF” as part of my signature. It took years to really accelerate the business model, and it happened not only because of CDF… but it was a beginning that can work for any company with silo management issues.

Friday, October 28, 2016

Un-common Language... communications in healthcare.

Among the many issues in American healthcare is the inability to share information among medical providers… patients, care-givers, institutions. This takes on many different forms and has several causes. Both form and cause need to be addressed prior to resolving the underlying issues of healthcare quality and costs.
One of the main issues in the cause column is that the many Electronic Health Records (EHR) do not easily talk to each other. This is a result of each of the EHR development companies (eg: EPIC and Cerner among hundreds) preferring to keep their systems proprietary… and the healthcare providers accepting this lack of standardization, because they want to maintain control over their patients. In both situations, the silo affect is willful protection of their profitability… not patient care or cost control. There is no standard way to share information between the silos, absence of such a common communication tool will limit the ability to reduce costs and improve care in the future.
The second issue is that medical professionals and business entities do not utilize a standardized language to describe any part of healthcare. For example, the ubiquitous drug “aspirin” can be described in electronic health records (the taxonomy or ontology of the data) in as many as 72 different ways. This problem makes it very difficult to accurately communicate between silos of healthcare. It makes it virtually impossible to standardize in ways that facilitate data statistics and algorithms... therefore analytics and clinical studies are hamstrung.
In other industries (financial for example) there has been standardization that allows for communication and aggregation of information. One can easily establish a link between one’s bank, investment, insurance, tax and debt accounts, for example. But in healthcare, an individual has no way to pull together their historic medical records… physician visits; prescription history; blood and image diagnostic work; hospital surgery records; vaccinations, and so on. Even though federal law has established the requirement that a person be able to get access to her records… it is required only that they be emailed (with no requirement for promptness), faxed or mailed on a memory device. This makes the record unsearchable, and virtually unusable during emergent situations.
All of this lack of communication in healthcare means that a patient cannot actually ‘own’, and carry with them, their personal medical history. This leads to situations where treatments are delayed, or repeats of diagnostic studies are necessary… adding costs and exposure to radiation… never mind, inconvenience.
There are two ways that we can, in the USA, take control of our health record. The first will likely never happen… have the federal government mandate a standard communication format, and require on-line access to an individual’s medical records. While this was done at the start of the digital revolution in diagnostic imaging with a standard called DICOM, to which all medical manufacturers must comply in order to achieve FDA approval… it seems the electronic medical record software used by all institutions and physician offices is well beyond standardization.
The second way seems more achievable. By individuals demanding access to their medical records in a digital format, they can take control of their history. This would have to be done as an individual, or by some sort of aggregator. It is the future, but when will it come?
It is somewhat obscure to envision a state where we have our personal medical records in one place, accessible to anyone to whom we want to deed access. This could be for emergent situations; second opinions; predictive analysis and so on. But we must start somewhere.
By asking our medical providers to give us our digitized records, and keep them in one place, we have a start. At least then if we need them on short notice, they are in one place. This would include previous blood or other diagnostic tests. Medical images (CT, MRI, Xray and UltraSound) are all digital today, and copies can be maintained by the individual. Records of vaccinations, flu shots and such are also important to have in one place. It is a start, but not enough.

Wednesday, October 26, 2016

So what is the 2016 election really all about?

So what is the 2016 election really all about? 

As usual there are different things for different folks… from being a historic GOP or Dem full ballot voter; to those checking all the issues that impact them personally; and finding a candidate or ballot issue that matches each, as closely as is possible. This probably doesn’t give anyone satisfaction, since democracy is not that granular, therefore individual needs cannot be assuredly satisfied with a single vote.

Democracy is not many of the things we believe it to be. As an example, it is not a “majority rules” form of government… except in 22 countries of the world who require all eligible voters (usually based on age) that are listed here http://www.pbs.org/newshour/rundown/22-countries-voting-mandatory/ … In effect, the rest of the countries are being ‘ruled’ by the leadership of the winning political party that received the majority of the votes of those who did vote… Usually much less than 80%.

 An example of non-democratic voting processes, is the USA. In 2012 just 57.5% of eligible American voters actually cast a ballot. In 2000 only 54.2% voted in the election that ultimately put the USA into a war in 2001 that is (fifteen years later, it is still not over). Interestingly, the outcome of that election, was in effect, decided by only the nine members (5 – 4) of the Supreme Court of the USA (SCOTUS) that stayed a Florida State Supreme court decision of 4 – 3 and ultimately elected George W. Bush president. All of which means that a change of around 1,500 votes overcame the majority of the votes in the country based on the arcane Electoral College system established by the US Constitution Articles and its 12th Amendment. Hardly a democracy by the definition… but here I digress!

So, if one is not choosing to vote based on specific line item issues… what is a reasonable way to consider the election of 2016. It is relatively simple, in my opinion to see the number one issue on the minds of Americans… not war, not healthcare, not the deficit… it is more likely the issue of “government not working” at the federal level. Without attaching blame, let’s look at the mechanics of the “government not working” issue, and the resulting legislative acrimony.

To start, it is important to understand the structure of the US Government at the federal level. There is a separation of power between the President of the USA, the Congress and the Supreme Court of the USA. These three branches of government have different responsibilities that allow government to work (Congress) and to manage disagreements/interpret the US Constitution (Supreme Court of the USA, (SCOTUS))
.
The President has certain responsibilities under the constitution. S/he is primarily responsible for any international agreements, policies and non-declared wars (the type of which most USA military activity in the 21st Century, have been). The President is also the “leader” of the administration of the country within the boundaries and laws established by the US Constitution and Congress. S/he is also the morale leader in times of trouble, and celebration.

 The ‘framers of the Constitution of the USA’ established the US Congress with its two houses… one, the Senate is made up of two Senators from each state (50 x 2 = 100, today). With an age requirement (30 years old), and six year terms (a third is replaced every two years). The Senate was established to take the edge off the House of Representatives (which is based on population dispersion). The Senate is perhaps intended to be the wiser, more sedate, less tumultuous governing body in congress. Because of that, it was also chosen to give the President ‘advice’ relative to international wars; the nomination of Federal Judges; and leaders of Federal Agencies. In these situations, they are also required to give ‘consent’ to the ‘major’ nominations like Supreme Court Nominees, Ambassadors and Cabinet Members.

The House of Representatives, on the other hand, is based on each state’s population density percentage of the national population (there are 435 members of the house… eg: 27 are from the populous New York State and only 8 from Wisconsin a much lower density population state); the members serve only two-year terms (however there are no limits to the number of terms a Representative can serve).

This makes the House more volatile and prone to swings in policy based on the happenings of the day. Things like unemployment, healthcare, education and other personal issues, often cause significant swings in the politics of this legislative body. The wisdom of the Senate which must pass each of the House of Representatives’ legislative recommendations, prior to it going to the President, for promulgation, was seen by the framers of the constitution as having a ‘calming’ effect.  

The President can refuse to sign into legislation (veto) policies to which s/he disagrees. The Congress can over-ride a veto with a two-thirds majority in both the Senate and the House of Representatives. President Obama’s vetoes, for example have been overturned only once in eight years. So the ‘veto’ is a big hammer that the President can swing on the Congress.

The foregoing is an overly-simplified version of what happens in the legislative process of the USA. It is however critical to understanding why government is not working. If the leadership of either the Senate or the House of Representatives (or both), is in disagreement with the President for political, economic or other reason, they have the ability to hold up any, and/or all new legislation the President wants to pass*. This is critical in the 2016 Presidential election, simply because promises made by a Presidential candidate may not necessarily be passed into legislation, if the leadership of the House and Senate cannot, or will not agree to it.

So in my opinion, there is only one issue in 2016 Federal Election… when a President is elected on November 8th, 2016, will s/he be able to accomplish the goals to which they aspire?

It is the structure of the government that may give us the answer, if the past 20-year-history can lead us to better judgement, in the future. The President of the USA, for all the apparent power s/he may seem to have, cannot move the country in a significant way, without having agreement with the Congress, and in many ways, the Supreme Court.

The twenty-year-trend has been toward polarization between the President and Congress, so legislation has been very slow to pass. Yet, clearly there are significant domestic issues that need to be addressed. Based on structure, it is my opinion that the only way to deal with the needs of the country (infrastructure, healthcare, domestic security, social security, education) is to elect a President who can manage the relationship with congress on a win/win basis. There is a secondary issue that ‘might’ help… that being, to elect a President and Congress (House and Senate) from the same party in order to get legislation flowing. Although absent managing the relationship with Congress, even same party officials often disagree on issues (Obama’s first term for example).
Primarily the election of a President should be based (again in my opinion):

1) on electing a person who has demonstrated the ability to understand and work with all branches of the federal government;
2) it is critical for the incumbent to also understand, and be capable of working with the military, Governors of State legislatures, municipal leaders and leaders of other countries
3)  on understanding that the USA is a daunting leadership quagmire, one that is very different from being a business or institution
4) knowing the gravitas of also carrying the mantel of decisions that perhaps could impact the globe… pollution, power, human migration and nuclear proliferation to mention a few.

The main crux of this note is that it is important to vote… but also to understand what is in the balance of our votes… and it will be the union of many votes that gets our Legislative Bodies to work with the Leadership through rightful and thoughtful use of our obligation.


Notes: * (an exception to this is the budget of the USA: there is legislation in place that states that if the new budget request from the President in any one year is not passed by a pre-determined date, the budget of the prior year is repeated).

This is an interesting website: https://ballotpedia.org/United_States_House_of_Representatives_elections,_2016



Thursday, October 13, 2016

USA Election 2016... things to consider...

The Election in the USA … this is a long post, but not when comparing the time to read it, and then “think” about the election, and the impact on our personal lives.

One should be sensitive to surroundings these days when ‘thinking’ about the 2016 Federal Election in the USA. I write ‘thinking’ about it because it has such a huge potential impact on the future of America… it is important to ‘think’ about what action to take in the voting booth.

The election is important because of things that can happen in the four-year term of the next President… as well as the long term impact of decisions made by the President, Congress and Supreme Court. This cycle will see significant global changes requiring the next President to wrestle with such issues as:

a)      a) in global life (human, animal and plants) because of environmental issues (weather, carbon fuels, global warming) that will strain not only relationships between countries, but between individuals within many countries
b)      b) strains in global/macro-economies because of the rise of major population areas’ (India, China, Brazil) economies through better education; lower and fluctuating wages; the impact of conflicts and resulting migration; the application of significant technological breakthroughs in machine learning and applications of the digital revolution and robots
c)      c)  the hierarchy of countries based on the ability of one of many to wage nuclear war and the change in propensity to use such weapons whether the country is a super-power or not… Russia, India, Pakistan, Ukraine, Israel, North Korea among others can deliver a weapon, somewhere in the world that could start a chain of events leading to disaster

 In the domestic cycle of four to eight years the next President has to make decisions that lean on each of the global issues above (among many others), and importantly lead and influence decisions that directly impact domestic life… such as developing and implementing strategies:
a)     *  to improve infrastructure such as highways, bridges, airports… in order to ensure there is not a breakdown in the ability to move goods and services
b)      * to protect the colossal amount of data developed by the government agencies from cyber attack
c)      to ensure the banking, patent, internet and investment systems are robust, fair and protected from conflicting influence.
d)      *to revamp the education systems and motivation to maximize the use of education by the population to regain leadership in technological and societal evolution
e)      * rebuild the delivery of quality, affordable medical services, and motivate the population to utilize more, healthy life-styles to reduce the costs of poor health on the economy
f)       * to manage the debt in a way that keeps it serviceable, without international leverage

The leverage that the President will need to use will be based on his/her ability to work through the various levels of government (municipal, state and federal), and the political parties, not to mention significant regional bias. A problem with the “big picture” issues above, is that all of them depend on the interaction of the layers of government and leadership of each, to get things done. Without effective up/down and across communications among the governments, things like policing, education, banking and so on, cannot be impacted or work effectively.

The most critical jobs of the President of the USA are in the areas of international affairs, defense of the homeland (military, environmental issues) and so on. In these, s/he can act somewhat independently as long as budgets are available. Beyond these, the President must work with Congress to accomplish the goals of his/her platform. If there is symmetry in the goals (based on the political numbers in the Senate and House of Representatives) of the two governing layers of the country, it is easier to accomplish shifts in strategy that are likely needed to move the country in a significant way.

Without getting too deep into the issues of governing with less symmetry, one can reasonably assume that it is important to have symmetry. When big change is needed in the USA (the issues listed above are “big change”) the President needs to have his/her party in control of both the Congressional House of Representatives and the Senate.

At the same time, the country needs to have a judicial system that is capable of timely decisions across the federal civil, criminal and family court structures. While this starts with the Supreme Court, it is important to have all levels of courts functioning. The next President will have the opportunity to nominate several new Justices to the courts, including the Supreme Bench… starting on Day One with a replacement that will again give the court nine justices.

So, these are large issues, and our vote in November looms larger with the reduction in days forward to make a decision… as I write this, we have 30 days before finally voting. The surroundings that I mentioned being sensitive to at the outset are important because the very process of becoming educated on the issues means listening to, watching or reading sources of information that also insert bias more than at any time in the past. The process of “reporting” is no longer pure enough to trust “reports”. In effect, much of what we get as “news” is in fact commentary.

So once one’s store of information on policies, personalities, status quo is informed, I think it is important to find a way to metabolize the available information and come up with a decision on how to vote the ticket that will be presented in the voting booth. This means voting what is called the “top of the ticket” for President… and the down ticket… for Senator, Congressman in each district, and Judges, mayors and for many different “issues” that are on the ballot around the country. There is interaction between the top and all of the others… but particularly the Senate and House… important interaction that can facilitate a rational President… or keep him/her in check if necessary.

It is very hard to get away from momentary influences and the situation this year seems more dynamic than in any election in which I have participated. But that dynamic nature means it is even more important to make an educated, thoughtful decision. The issues of personal conduct, in my opinion are important… what conduct, in what conditions are important in the elimination of a candidate anywhere on the ticket? Not for me to judge, but for us to contemplate.

This election is about avoiding a nuclear war, and the genocide of millions of people based on one or another leader’s whim. It is about ensuring resolution to awesome issues like global warming; human migration and suffering; potable water and safe food availability and so on. It is of course also about national issues… as listed here… but if America wants to be the big dog in the world, it has to get off the porch and become a welcome leader, again. Leadership isn’t about the bite anymore (too many nuclear warheads), it is about influencing rational development of our globe and beyond. 

This is what we are voting about in November… it is more than one’s personal benefit, although it is to some extent about that… if we count surviving in a nuclear environment; or one with “storms of the century”, every week; or a country turned on itself with its guns and money.

Along with these issues one can add that it is an obligation, as a citizen, to be an informed voter… and to vote. I hope each of us will.





Friday, July 15, 2016

How will we survive… not with incremental change…


Consider the $3 Trillion healthcare bill that we had last year…. These are all the costs of generating or curing, hopefully healthy people in the USA, each and every year. For those who know a little about numbers, the “Rule of 70” tells us that if the cost of healthcare continues at the average annual rate of 6%... the cost of healthcare in the USA in 2027 will be about   $6 Trillion… that’s $6,000,000,000,000.

That is also over 17% of the USA GDP... that is a GDP that is growing at an annual rate of less than 2.5%.
So, what will the GDP in the USA be in 2027 if it continues to grow at the 2.5% rate. Simple compounding gets us to $23 trillion, or so. By that time, 2027, healthcare will be over 25% of the GDP of the USA. Interestingly, the Federal Government budget is only $3.7 Trillion.

Healthcare costs for the nation seems to be completely unsustainable! Yet, we continue to work in the government as if we can just print money to keep its part floating… but what can the folks who are spending from their own bank account do?

The current model in the US, with the highest per capita costs in the developed world is also getting the poorest quality… aside medical research and cancer survival rates, the USA ranks 10th or worse in each other category (see the graphic below). Again, if the dollars are unsustainable, what will happen to what is already among the worst outcomes… especially when we are paying out over 2 times what the other counties are paying?

The incremental changes we discuss in the government generally keep the ecosystem currently in place for healthcare in the USA the same as it has been since the 1950’s. Doctors, Hospitals, Pharmaceutical companies and Insurance companies are the focus. Regulations and standards are based on keeping them profitable, under all circumstances… regardless of quality. The system is not working!

The focus needs to be on the patient. The patient needs to be in control of her file and able do decide what is best for her and her family. This is not the case today, as anyone with an experience bordering on or including a catastrophic event. If other countries can do it (again, have a look at the chart below), then the USA can do it, too.

But it needs to be brave!


But it needs to be brave!

Saturday, July 9, 2016

Wisdom, why is it missing in our lives…


Wisdom is the ability to think and act using knowledge, experience, understanding, common sense, and insight. Yup, I lifted that from my favorite web spot, Wikipedia.

How does one come by having wisdom, without going through the gambits of life, growing up… making mistakes, doing some things right and so on? For centuries this came from parenting, grand parenting, experience and education. There is the sense that the devolution of the family unit has contributed negatively to the transition of wisdom from one generation, to the next. Parent to child and grandparent to grandchild… missing in many families due to distance… in miles and culture.

If this is correct, and if wisdom has value to society, it is likely that the shortage will be in the first thirty years of people’s lives. Also, one can posit that the accumulated wisdom in the last 30 years of people’s lives might also go to waste since it can’t be handed down to grandchildren for the same reason…

Some would have us believe that all of the lost valuables like a grandparent spending quality time with a grandchild teaching an old technique like woodcarving, or talking about family history are useless… I disagree. That allows the genes passed along to be enabled with memories, ideas, creativity and so on.

Parents talking with their older children about keeping an even temper, about how to treat people and how to make life better, also can have a deep impact on how they develop into adulthood. These things play out later in life… and when absent occasionally result in deep rooted problems for next-gen families… money and health problems are examples often of not listening to or having access to wise counsel.

Many of these conversations don’t happen today. It is reflected in many ways, and unfortunately may also be the cause of the dysfunction we are seeing in parts of our society today. Clearly people not being able to absorb change in our society and environment may also be those not having had good family passage of wisdom… or willingness to listen for wise counsel… or a willingness to look for it.

Recently I viewed a re-run of a movie with Robert De Niro and Anne Hatheway as the stars, called The Intern. At one stage he said in-character as Ben Whittaker “you are never wrong to do the right thing”… how could he know that, except that he had over forty years of experience in business. He was, by being the intern (in reverse), passing this wisdom on, to his “boss”. This is a great example of passing on wisdom to person who never had parenting or management because she started the business right out of college (à la Mark Zuckerberg, Bill Gates, Steve Jobs).
 
So, what do we do about this lack of wisdom hand-me-down thing? Honestly, I am not sure. 
I know in business there is the potential of using the “Intern” idea. I disagree with the use of 
‘consultants’ who are working with strategy … I was involved in some of that and failed in my
opinion, to be of great utility. But as a supporter of a young executive, perhaps I have had 
occasional experiences that were more successful. I think similar things can happen between 
youth and senior who would stand in occasionally for the missing grandparent. Similar to the
very successful Big Brother and Sister programs… only one extra generation beyond.

Wearable personal monitoring apps and devices… if not used to develop actionable information, what good are they?
There are as many viewpoints on this issue as there are people utilizing the devices… many are actually using them to improve performance. For example, a runner might use a device to not only time a training run, but to manage her heart rate during wind-sprints and track the data with an eye to reducing heart rate while increasing speed over the training period.
My Samsung device monitors my activity by the hour, alarming me to get up and move if I am inactive for the previous 60 minutes. The goal here is to allow circulation of oxygenated blood to the extremity muscles and allow your heart to pace up, your lungs to expel gases, your organs to remove toxins and so on… all good. Later in life this helps avoid leg cramps and poor circulation.
Sleep monitoring is interesting, as well… My Band from Microsoft lets me know my sleep habits. When normally I get my 8+ hours of sleep it tells me that my early sleep was not of high quality… not Stage 3 SWS or REM so to speak (the former helps the body regenerate and the latter, regenerates and organizes the brain and memory). Then it comments that among other things, having an alcohol drink in the hours before going to sleep will disturb several hours, until that toxin is run through the liver and kidneys enough to get it out of the blood stream… then in fact, the better Stages III and IV, and REM occur. When I don’t have a drink for a few evenings, sure enough, sweet dreams early in the rest period. I suppose this is actionable monitoring in which I should participate… hmmm, do drink or not to drink alcohol before bed?
So, in some ways, wearable devices can be useful… but only if we take action, based on the information they are developing. Much of that information has to be trended in order to be useful. If the app doesn’t trend the data, or we don’t record it manually, it usually is useless. As well, if one is going to use it with weekly interfaces with a coach, or with a visit to a physician, it is a must to have trended data… allowing us to know if we are getting better, getting worse… is the new normal being too high or low…
Recently my blood pressure which I have been trending for over three years started to trend higher. My resting heart rate had also begun trending higher, from rest rates around 45 up to 60 and BP moving to 135/90 from 110/70. The trending wasn’t constant when looking at a daily plotting.
I had a cardiac check-up scheduled, so I took my data with me… I had a suspicion that my new work and all the flying I was doing had something to do with it, so I also plotted my flight schedules against the trend lines. Sure enough the daily increases in BP and HR a couple of days following extended flights were significant… and causing the trailing averages to go up. A new medication and pressure stockings for flights put everything back to my target pressures on average and daily… that’s action based on a wearable. When I stop flying for work again, I will return to the past meds and tactics.

If we are not using the information, why have it… I suppose my Microsoft Band or Samsung Gear II look cool… but not as cool as keeping things in a healthful status. It is something that we should work on… how to put all this information to use. There are Bluetooth weight scales, blood pressure and heart rate cuffs, pulse
oximetry, and ec(k)g t-shirts that are simple, cheap and useful in allowing us to better inform our caregivers about our healthfulness. You can input things like coffee and calorie consumption, exercise calories burned, sleep data and so on… again, all useful for when we become symptomatic… or even before if the physician knows how to interpret the data. We should put them and new ones coming, to use… and take action to achieve our best possible healthfulness quotient.

Friday, March 18, 2016

Evacuation Day... Boston, March 17th, 1776

St Patrick's Day, in Boston...

It is likely little known that Boston has two celebrations on March 17th each year... on the one hand, they celebrate the Irish... and the other they celebrate the Evacuation of the British... they call it Evacuation Day. In 1775, the British had blockaded the Boston Harbor... it was a troublesome time, around the American Revolution.

There were the British in the harbor trying to starve the Americans into submission. They were having nothing of it, and plotted to move canon into place on the hills overlooking the harbor... that was laden with the British blockade of ships. While this had all transpired over many battles, and eleven months... it was on March 17th, 1776 that the British realized that the Americans had, using subterfuge, successfully moved canon from the captured Fort Ticonderoga into place, and they were sitting ducks in the harbor. The British, on the first tide and favorable winds, retreated to Halifax... just another in many ties Boston has with Halifax, Nova Scotia.

So, the Irish celebrate not only St. Paddy's Day... but a veritable expulsion of the British that they appropriately name "Evacuation Day".

Double-Double-Triple, too sweet...

On Thursday this week I was in Boston on business. We arrived at our downtown meeting place, at the corner of Berkeley and Boylston Streets… that is about 300 yards from the finish line of the Boston Marathon.

We were early for our meeting, and it was St. Patrick’s Day. Boston is a most exciting city, on the 17th of March each year… a great parade takes place to celebrate the greatness of Irish Pride… we decided to walk a little toward the Starbucks on the corner. It was a beautiful day, mid-60’s… lots of people around… "coffee"? "Of course"!

We entered Starbucks… it was the first we had been in that didn’t have a seating area… just a narrow storefront, about six baristas, working steadily, to keep up with the 15 or so deep line up… it seemed not to move, but people were coming in and going out…

As we headed to the end of the line… we noticed a sign on the cash registers… hand- scribed… it said… credit and debit cards won’t work todayjust cash and Starbucks cards.
We arrived at the end of the line, followed by three young people, a lad and two lassies… clearly celebrating St. Patrick’s Day, wearing the green… they were excitedly discussing the payment signs… apparently, they always paid with their debit cards… and didn’t have enough cash to have the double-double-triple ‘too sweet what-evers’ that they wanted. 

I was mentally calculating if I had enough cash to gift them their coffees... but not fast  enough...

They had quickly realized that it would be at least five minutes before getting to the front of the line, and the cash register… they discussed "how long would it take to download the Starbucks app"?… "up-load their debit or credit information"… "pay for their treats"… of course… less than the time to get to the front of the line in a Starbucks… so they did! And happily they had changed from a cash to a debit, to a membership card society...

Life has changed!

When we later met with our business associates, we told the story... to support our thesis of changes coming, in retail medicine… how easily the young 'in green' people had adapted to the new reality in Starbucks… 

One colleague indicated that daily, he takes the Green line train on the MBTA into the city… when he has to change from the Green to the Red line at the Commons Interchange, he goes on his iPhone Starbucks app... orders and pays-for his regular double-double from the Boylston and Berkely Streets Starbucks… five minutes later, he comes up out of the Red Line subway station , conveniently in front of the coffee shop, picks up his double-double (without lining up), and walks across the intersection to his 20th floor office… 

Life has changed not only for the young people… we elders, too... our lives have changed!

This is but a small discussion of how things all around us are changing… are we ready?

No.... Better Get Ready...

Monday, March 7, 2016

What is acceptable production in Mexico... NAFTA

Recently I listened to the Donald, Bernie and others trumpeting about heroin in New England and how it was coming from Mexico. I thought it was coming through Mexico from Colombia... so I went looking for evidence of error... it is me that is wrong.

Colombia has reduced its heroin production and is down to about 2 metric tonnes of the stuff... from nearly 20... in the past ten years. Mexico on the other hand has replaced the Colombia production, and then some... this is a quote...

In contrast, opium poppy cultivation in Mexico remains high, and Mexico continues as the primary supplier of heroin to the United States.  Estimated cultivation of opium poppy reached 10,500 hectares in 2012, with an estimated pure potential production of 26 metric tons.

My disappointment runs deeply. I don't understand how a country with all the upside it has, can allow such an internal issue to exist. All they have to do is take the army in and wipe out the fields... not doing so makes one wonder about the leadership of the country... and perhaps, whether some of what the Donald is saying (although too bombastically) is correct. I suspect Donald would use Agent Orange on the fields, given his penchant for the spectacular.

The quote above is from The White House Office of National Drug Control Policy, and is written under the Seal of The President of the United States of America. Can one imagine what it must be like to be President Obama negotiating with the President of the United Mexican States, while knowing that the latter is fueling an American nation-wide epidemic, about immigration or NAFTA?  I don't understand how the USA can negotiate anything else, before ensuring that the manufacturing of Heroin is ended, before the other products manufactured in Mexico are allowed into the USA. 

I 2014 the estimate had become  about double that of 2012... it is growing larger! This during a period in which there was a concerted war by Mexico, on the cartels and drug trafficking. So, after writing and reading this discussion, I wonder "what is the answer?" Treat people well, treat people poorly... use a carrot, use a stick... care, don't care... what is the answer?

I don't think it has anything to do with immigration or the election. I think it has to do with helping the President of Mexico understand the difference between exports, and how one could impact the other.



Wednesday, March 2, 2016

What portion of $60 billion do we want to re-allocate...

Some research on annual healthcare costs, and where the money goes...

This is part of my series to document that individuals actually have more control on national healthcare costs than the government, insurance companies or politicians. There is a lot of evidence of this…

For example, in a January 10th, 2013 article in Forbes Entrepreneurs, Michael Bell wrote his reaction to data from Dr. Susan Dale Block of Bringham and Women’s Hospital in Boston. He wrote “It seems that no matter how much money you use during that last year/month (of a person’s life), if the person is sick enough, the effort makes things worse”.

We know that 30% of all Medicare costs (equal to about $175 billion) are spent in the last year of Medicare patients’ lives… and about 1/3rd of that in the last month (about $60 billion).

It is a relatively simple algorithm to state that ‘if’ a patient is very sick with end stage cancer, 'then' keep the patient comfortable; do not treat to extend life. By doing this, the Medicare system either saves a large portion of $60 billion, or uses it to ‘save’ lives. I am not suggesting that the decision be made without the patient’s knowledge; the decision is the patient’s. The obligation here is for the medical profession to ensure the patient is knowledgeable of her situation, and be allowed to choose.

We are all going to die. If we internalize knowledge about treatment, outcome, costs and so on, it is a simple leap to a better end. Should the motivation be to save money… likely not… that’s too hot. But just the knowledge that when we spend more, we likely “make things worse” should be enough.

Generally, people who know they are going to die, don’t want to go through excessive pain to live an extra day(s). It is also important for loved ones to understand the facts, and not get in the way. Is it a moral and ethical issue… only for the individuals involved? Perhaps, the rest of us, and the medical profession c/should stand aside.

How do we start the discussion and make this happen. It is a financial ethics issue, too.




Sunday, February 28, 2016

The Problems of Health Care... a series

My focus over the past four months has been the cost and delivery of diagnostic healthcare in America… trying to understand the basis for the high cost on the one hand... and the poor services on the other.

Getting to the poor services first... I am focused on diagnostics here... diagnostic imaging, blood tests, tissue analysis and so on. There are several aspects of quality that should be considered...
·        The time necessary to book a test
·        Having to go through a primary care or specialist physician in order to book a test
·        The time to be tested from the moment one enters the facility
·        The quality of the test itself…
o   In blood tests the way the sample is taken by the phlebotomist
o   The manner in which the blood or other sample is handled and protected
o   The positioning of the patient for the image
o   The protocol chosen and implemented for the imaging
o   The analysis of the test… imaging, blood or other
·        The time it takes for the report to be communicated to the referring physician and the patient
·        The ownership of the medical data; where it is stored; its availability over time

There are failures in each of these parameters and more. Patients report being verbally abused by administrative and medical staff. They often report a lack of facilities, appropriate apparel, and decency. They complain about questionnaires that are too long; not kept from one visit to the next; about much of the information having already been sent by the referring physician.

Why are these conditions being accepted by the patient… because historically they have not had an acceptable alternative. Their insurance company or physician has made the appointments and require the use of specific clinics. No alternatives are apparent to the patient.

The second area that is a serious impediment, to good care, is the cost of the test itself. Most patients depend on their insurance companies to pay for the test. But in nearly all cases, there is a ‘co-pay’ required in order to have the test done. Depending on the test, this could be well into the hundreds of dollars. Incremental tests could be extremely costly, and once the annual maximum on the policy is reached, the costs are so debilitating that many patients don’t have the test, or wait until the next annuity.

The many patients who don’t have health insurance are on their own relative to testing. They are cash payers, but are offered at ‘Chargemaster’ pricing… the list price of the hospital. They are rarely offered the ‘discounted-for-cash’ pricing. They also don’t realize that they can negotiate almost any quoted price… as long as it is done before the procedure. In many cases, the patient is paying three to five times the cash price… or more!

The discounted-for-cash price is an important issue in diagnostic medicine. This is a price that is negotiable when the patient has alternatives… and time. In emergent situations, it is almost impossible to bypass the Chargemaster price, the insurance co-pay and so on. In this situation it is important to have ‘catastrophic’ health insurance. Below is a general description of this type of insurance.

In combination with a ‘health savings account’ (HSA), patients can save enormous amounts for their healthcare compared to what they are paying today through their insurance programs… private or employer based. Depending on the patient’s income levels, the HSA, which is a pre-tax savings account, can reduce health costs by a level commensurate with her tax rate. The HSA  is explained below.

It would be interesting if employees could convince employers to option them the ability to take an annual cash replacement for their medical insurance… and stop paying the monthly deduction… saving them up to $10,000 a year in out-of-pocket insurance costs… for which they will still have to pay co-pays! The reduction could go directly into their health savings account.

Beyond the idea of the HSA and the potential of negotiating lower diagnostic costs (up-front)… here are a couple of other ideas on how to save healthcare costs
·        Reduce one’s risk of health problems
o   Exercise regularly (30 minutes a day at a heart rate of 120BPM… a brisk walk for example)
o   Reduce calorie intake to a targeted amount, replacing hunger with water
o   Wash hands regularly and avoid situations where one has to interface with sick people
o   Quit smoking and/or avoid contact with people who are smoking
o   Avoid sugar and sugar replacements to reduce the potential of diabetes
o   Reduce one’s stress… measure it with a smart phone app… set targets
o   Improve sleep habits… measure it with a smart phone app… set targets
·        Choose a General Practice physician who offers concierge services. These services are often not expensive, and give better access and annual check-ups
·        Have an annual check-up; have routine testing done based on pre-disposition analysis by the GP
·        Ensure all vaccines are up-to-date to avoid many diseases, including the flu
·        Keep automobile insurance up-to-date with medical coverage (a cheap catastrophic insurance). Keep the car well serviced… the most expensive preventative maintenance is ‘that which is not done’

There are many other ways to avoid health costs… particularly if they are started early with children. Don’t let them get into bad habits… sedentary life-styles, over-eating, dependence on fast-sugar foods and drinks, brushing teeth twice a day, washing hands, staying home when sick, staying away from sick people and so on.

Relative to the issues at the beginning of this post… poor services. Understand that there is no need to put up with any of the issues listed. We all have choices we can make… but always register complaints with the management. If they don’t know how you are being treated, they can’t react. There are many websites where comments can give you and others a heads-up about poor service… and especially good service. These generally are in the USA… but they exist in Canada and other areas in the world.


http://www.realsimple.com/health/first-aid-health-basics/what-to-ask-your-doctor/how-to-complain-about-your-doctor




                                                                                                                 

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Blueknowser

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Grad. Saint Mary's University, 1975, got into the medical device business initially in sales, then various management positions up to president, all in Medical Devices. I prefer therapy products over diagnostic, but they are all fun, and in a way have defined my life. I have now evolved, with help from my 35 year partner Lynnda with whom I now share every hour. I am into staying healthy, photography, kayaking, bicycling, gardening and two books a week. I wish I had gotten to this stage earlier!